Healthcare Provider Details

I. General information

NPI: 1477551661
Provider Name (Legal Business Name): RUSSELL GORDON MARQUARDT SR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 CHATBURN AVE
HARLAN IA
51537-2009
US

IV. Provider business mailing address

4022 MAIN ST
ELK HORN IA
51531
US

V. Phone/Fax

Practice location:
  • Phone: 712-755-5130
  • Fax: 712-755-4445
Mailing address:
  • Phone: 712-764-4642
  • Fax: 712-764-4643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number888
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: